Dialysis Access Hemorrhage: Access Rescue from a Surgical Emergency

Inui, Tazo; Boulom, Valy; Bandyk, Dennis F.; Lane, John S.; Owens, Erik L.; Barleben, Andrew

doi:10.1016/j.avsg.2017.03.003

Cited by 15 publications

(9 citation statements)

References 10 publications

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“…22 However, in 1 retrospective case series of 26 patients with potentially fatal vascular access hemorrhage, only 16% had tourniquet application in the ED, but all patients required emergency operating room intervention, making it unlikely that the tourniquet itself resulted in the need for surgical repair. 23 Eighty-five percent of patients in this study had successful access salvage in the operating room. 23 Direct pressure, which can be supplemented by topical hemostatic agents or reversing systemic coagulopathy, will control most bleeding and should be used preferentially when possible.…”

Section: Discussionmentioning

confidence: 79%

“…23 Eighty-five percent of patients in this study had successful access salvage in the operating room. 23 Direct pressure, which can be supplemented by topical hemostatic agents or reversing systemic coagulopathy, will control most bleeding and should be used preferentially when possible. 24,25 However, tourniquets may prove life-saving in cases of exsanguinating hemorrhage;…”

Section: Discussionmentioning

confidence: 79%

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Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post‐mortem analysis

et al. 2020

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Background: The US military has prioritized battlefield hemorrhage control. Researchers credit tourniquet use, and a novel trauma care training program, with saving 1000-2000 lives in Iraq and Afghanistan. The Stop the Bleed campaign translates these lessons learned to the public. This is the first analysis of the potential impact of this newfound knowledge about tourniquet use for extremity fatal vascular access hemorrhage in a civilian population. Fatal vascular access hemorrhage includes bleeding from arteriovenous fistulas and grafts used for hemodialysis and central venous catheters. Methods: This is a retrospective study of decedent records. We selected Maryland death records from 2002-2017 using the following search terms: "graft," "shunt," "fistula," "dialysis," and "central venous catheter." The records were analyzed for potential survivability with a checklist of military criteria modified for a civilian population. Suicides were excluded. Two reviewers independently classified the deaths as either potentially survivable or non-survivable, and a third reviewer broke ties. Results: There were 111 deaths included in the final analysis. Ninety-two of the 111 decedents had potentially survivable extremity fatal vascular access hemorrhage. The remaining 19 records were excluded, because they did not have extremity hemorrhage. Zero decedents had hemorrhage deemed to be non-survivable with prompt tourniquet application. Conclusion: This study identified 92 Maryland extremity fatal vascular access hemorrhage decedents who potentially could have survived with tourniquet use-an average of 6 per year. These results suggest the need for further epidemiology investigation, as well as exploration of the risks and benefits of teaching and equipping vascular access patients and their caregivers to use tourniquets for life-threatening bleeding.

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Section: Discussionmentioning

confidence: 79%

Section: Discussionmentioning

confidence: 79%

Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post‐mortem analysis

et al. 2020

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“…In their series, there was no mortality from fistula hemorrhage. 3 Jaffers and Fasola have described their experience with the management of 28 ulcerated fistulas. After operative intervention, they managed to salvage all 28.…”

Section: Discussionmentioning

confidence: 99%

“…Patients presenting with acute bleeding from an ulcer over a fistula should be managed as an emergency. Digital pressure, compression dressings, tourniquets, and temporary hemostatic stitches in the emergency department are bridges to definitive surgical or endovascular intervention 3 . An ulcer over an AVF or AVG that has not yet bled should be evaluated urgently as preemptive intervention can prevent a catastrophic hemorrhage.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of operative intervention for ulcers over hemodialysis arteriovenous access

Gunawardena

Sharma

Mehra

2023

Hemodialysis International

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Introduction The native arteriovenous fistula (AVF) is the gold standard for long‐term hemodialysis access. When native vein options are exhausted, arteriovenous graft (AVG) becomes the next choice. An ulcer over an AVF or AVG is a serious condition with the potential for life‐threatening hemorrhage. Objectives This study aims to present our experience with surgical management of ulcers over AVFs or AVGs. Materials and Methods Electronic records of 26 patients who underwent 27 consecutive surgical procedures for ulcers over AVFs or AVGs from December 31, 2016 to December 31, 2021 at the Royal Liverpool University Hospital were retrospectively analyzed. Results The majority were males (14/26, 53.8%) and the median age was 64.5 years. Operative repair was required for 25 ulcers over 24 AVFs and 2 ulcers over 2 AVGs. Ten patients (37%) presented with bleeding. Seventeen (63%) had impending bleeding suggested by a thin soft tissue covering or a false aneurysm at the site of the ulcer. Previous endovascular intervention for fistula outflow stenosis was a significant predictor for presenting with bleeding (p = 0.031). All ulcers (27/27, 100%) underwent excision and primary skin closure. Fistula wall defects were directly repaired in 18/27 (66.7%). Four/26 (14.8%) fistulas had to be ligated and 2 (7.4%) had end‐to‐end re‐anastomosis after excision of damaged segments. Three/26 (11.53%) fistulas thrombosed immediately after the intervention. The overall fistula salvage rate was 73.08% (19/26). There was 1 (3.7%) patient mortality due to bleeding from wound breakdown after surgery. Conclusions An acceptable fistula salvage rate can be expected following surgical repair of ulcers over AVFs and AVGs. A history of previous endovascular interventions for fistula outflow stenosis was a predictor of bleeding from these ulcers.

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“…Hemodialysis (HD) requires access to blood circulation and connection to the extracorporeal circuit; 2 broad categories of vascular access are used, namely central venous catheters and arteriovenous (AV) accesses, such as AV fistulas (AVFs) and AV grafts (AVGs). While AVF is the preferred access type in most patients, both AVFs and AVGs are prone to complications, including the development of aneurysms and pseudoaneurysms, which are widening of the access that involves all or some components of the access/vessel wall [1,2]. Pseudoaneurysms lack an endothelial lining and are frequent complications Blood Purif 2021;50:636-641 DOI: 10.1159/000515642 of excessive needle puncture in one area of the access.…”

Section: Introductionmentioning

confidence: 99%

Artificial Intelligence Methods for Rapid Vascular Access Aneurysm Classification in Remote or In-Person Settings

Krackov¹,

Sor²,

Razdan³

et al. 2021

Blood Purif

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Background: Innovations in artificial intelligence (AI) have proven to be effective contributors to high-quality health care. We examined the beneficial role AI can play in noninvasively grading vascular access aneurysms to reduce high-morbidity events, such as rupture, in ESRD patients on hemodialysis. Methods: Our AI instrument noninvasively examines and grades aneurysms in both arteriovenous fistulas and arteriovenous grafts. Aneurysm stages were adjudicated by 3 vascular specialists, based on a grading system that focuses on actions that need to be taken. Our automatic classification of aneurysms builds on 2 components: (a) the use of smartphone technology to capture aneurysm appearance and (b) the analysis of these images using a cloud-based convolutional neural network (CNN). Results: There was a high degree of correlation between our noninvasive AI instrument and the results of the adjudication by the vascular experts. Our results indicate that CNN can automatically classify aneurysms. We achieved a >90% classification accuracy in the validation images. Conclusion: This is the first quality improvement project to show that an AI instrument can reliably grade vascular access aneurysms in a noninvasive way, allowing rapid assessments to be made on patients who would otherwise be at risk for highly morbid events. Moreover, these AI-assisted assessments can be made without having to schedule separate appointments and potentially even via telehealth.

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Dialysis Access Hemorrhage: Access Rescue from a Surgical Emergency

Cited by 15 publications

References 10 publications

Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post‐mortem analysis

Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post‐mortem analysis

Outcomes of operative intervention for ulcers over hemodialysis arteriovenous access

Artificial Intelligence Methods for Rapid Vascular Access Aneurysm Classification in Remote or In-Person Settings

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